Out of the shadows

She could be the girl next door. With strawberry blonde hair and a lightly freckled face, Cotie is 26 but could pass for half-a-dozen years younger. It’s only when you talk with her that you learn Cotie — who asked to be identified only by her first name — has lived an uncommon life. She is a survivor of sex trafficking.

Beginning at age 19, Cotie was pimped out or walked the streets, offering sex for money for her next high. She was physically and emotionally abused and sexually assaulted.

Cotie didn’t have help to avoid what she and others like her call “the life,” but the University of Louisville is working to give victims like Cotie assistance to leave the life behind or elude it altogether.

Sex and labor trafficking are, as defined by the National Human Trafficking Hotline, “a form of modern-day slavery in which traffickers use force, fraud or coercion to control victims for the purpose of engaging in commercial sex acts or labor services against their will.” Nationally, more than 8,500 cases of human trafficking were reported in 2017. Almost 6,100 involved sex trafficking, but researchers warn that as many as two-thirds of cases are never reported.

Several departments on UofL’s Belknap and Health Sciences Center campuses began working a few years ago to address human trafficking through the university’s quadruple enterprises of education, research, clinical care and community engagement. Today, the faculty involved share information, and the university is leading the way nationally in educating health care providers to recognize signs of trafficking.

UofL’s approach to studying the problem is truly transdisciplinary. Faculty members in social work, criminal justice, engineering, law and medicine are investigating various aspects, from the mental and physical health of victims to the routes and logistics of the actual trafficking.

Cotie didn’t have access to most of UofL’s services until she was leaving the life. But if she had, it could have made a world of difference.

•••

Cotie grew up in a small town near Lexington, Kentucky, with abusive parents who used alcohol and drugs.

“My addiction started with drinking,” she said. “My mom had keg parties, and it was normal for all the kids to come to my house. I grew up watching my family grow pot. My mom hung the marijuana plants in my closet to dry them. And she later started smoking crack.”

Cotie emulated her mother and life went downhill from there. She dropped out of high school and drugs consumed her. Cotie’s early marriage initially helped curb her substance abuse, but “one day, I picked up a drink and I couldn’t put it down.” She then gave birth to twin girls. Drink gave way to pills and then to intravenous drugs. Her husband was sent to prison — Cotie doesn’t volunteer why — and she needed to support herself and her daughters.

She’s hesitant in talking about how the trafficking first started: “I needed money to take care of my children, and I met people that told me there was maybe somebody I could go meet to maybe make money with.”

She was understandably uncomfortable — at first. Then, “I was making money … so it became normal-like. I justified the behavior to take care of my children. But really it was for me to keep my addiction going.”

Cotie eventually lost her house, job and car. Her daughters were removed from her custody. One day, after an arrest for passing a cold check, she went to her small county hospital and told a lie to get help. “I told them, ‘Either you help me or I’m going to harm myself.’ ”

After a short stint in a recovery program, a counselor who knew Cotie was caught up in sex trafficking told her about Louisville’s Kristy Love Foundation.

•••

Founded and managed by Angela Renfro, the Kristy Love Foundation provides assistance to women trying to leave the life. Renfro herself is a survivor. “Kristy Love” was the name her pimp made her use.

“We help survivors have healthy options,” Renfro said. “What society says is normal isn’t normal to us. The women here get a taste of freedom from trafficking, drugs, alcohol. It makes them drive even more like I did — to fight for that [new] life and not go back to the other one.”

Jennifer Middleton, associate professor in UofL’s Kent School of Social Work, turned to the Kristy Love Foundation to implement Project STAAR: Survivors of Trafficking Creating Art, Agency and Resilience. Middleton, social work colleague Lesley Harris and doctoral student Jaime Thompson help small groups of survivors make art. The art empowers them to create and also launches group discussion of their experiences during counseling sessions.

Cotie was one of the participants and hers was just one of the affecting stories UofL researchers heard. Theresa Hayden, assistant professor of criminal justice who directs UofL’s Human Trafficking Research Initiative with Middleton, has provided other examples to students in her human trafficking course.

“Their eyes are opened the first week of class,” said Hayden. “It’s exploitation of human rights — and the greed that drives them [traffickers] …. They begin to see that vulnerability, that victimization.”

The growing exposure to information about trafficking was transformative for Hayden. Her educational and research experiences led her to chair the board for PATH (People Against Trafficking Humans) Coalition of Kentucky, a nonprofit devoted to education, awareness and, ultimately, plans for a home with trauma-informed services for 18- to 24-year-old survivors seeking a safe place.

The lack of a home is a major factor for youth victims, and research coordinated by UofL and several community partners is providing data needed to bolster policy and enforcement measures to combat the problem. The Youth Experiences Survey (YES), conducted by UofL found 40 percent of 132 homeless youth aged 12-25 surveyed in Louisville and Southern Indiana in late 2016 reported they were victims of sex trafficking, mostly in exchange for money or lodging, and the average age of their first such experience was 16.

“Everything we’re doing builds on the YES survey,” Middleton said. “It served as a call to action in our community and our state.”

“Human trafficking represents the worst form of abuse, often to children, and it is increasing in Kentucky,” Attorney General Andy Beshear said. “Research such as UofL’s study is important and will help our efforts to combat this form of modern-day slavery.”

•••

While Cotie was in the life, she occasionally visited an emergency room or trauma center but received little understanding from the providers. “Once, I was hallucinating on meth, and the emergency room discharged me after four hours. It was like I didn’t matter. I was telling them I had a problem but they wouldn’t help me.”

Although Cotie’s negative experiences did not occur at UofL, ensuring trafficking survivors receive proper care is something the university is working to address. Nationally, as many as 88 percent of trafficking victims interact with health care professionals. However, the health care workers’ ability to recognize the signs of trafficking often is severely lacking.

The UofL School of Medicine created a simulation-based medical education curriculum to prepare students to recognize victims and intervene on their behalf. The only such curriculum in the nation, the Medical Student Instruction in Global Human Trafficking, or M SIGHT, uses online learning, medical documentation and standardized, patient-based simulation to prepare students to see the signs of human trafficking.

The brainchild of Olivia Mittel, associate professor of pediatrics, M-SIGHT trains medical students in “trauma-informed care, which is health care delivered with an understanding of what patients experiencing trauma need,” she said. “The training helps future physicians learn how to ensure confidentiality, ask non-judgmental and open-ended questions to glean information and gradually progress from less invasive to more direct questions.”

M-SIGHT includes a standardized patient simulation where an actor portrays an adolescent female with symptoms of a sexually transmitted disease, as well as the characteristics of victims of human trafficking: poor eye contact, reluctance to communicate with the physician, inconsistencies in what is communicated, tattoos that could suggest branding and evidence of physical abuse. The goal of the simulation and its application is not to force intervention, but rather to build trust, said Carrie Bohnert, director of the standardized patient program at UofL and Mittel’s M-SIGHT colleague.

Medical schools from Harvard, University of South Florida and University of Arkansas have expressed interest in UofL’s training. “There is a wide array of methods for creating human trafficking simulations, and we hope our process will inspire others to create similar interactive educational programs,” Mittel said. Adds Bohnert: “The ultimate goal, of course, is to help human trafficking victims receive both the health care they need and interventions that stop their exploitation.”

UofL clinical care providers already are helping trafficked patients. Physician Jennifer Green is the only child abuse pediatric fellow in Kentucky and specializes in treating patients who are suspected of being physically abused. Emily Neal is a forensic nurse specialist and sexual assault nurse examiner who works with her.

How they treat these patients can be as individualized as the experiences the patients have. After reporting suspected sex trafficking cases to the Cabinet for Health and Family Services (CHFS) and law enforcement, Green and Neal assess their acute medical state to determine if they need testing for sexually transmitted diseases, detox treatment to withdraw from drugs or alcohol, or psychiatric intervention for acute psychosis.

“Once the acute conditions are addressed, then we evaluate their chronic medical state,” Green said. “We have a global, multidisciplinary approach to these patients, trying to address their complete medical and psychological needs.”

With law enforcement and CHFS taking the lead, health care providers stay involved with the patient as long as they can. “We know about 70 percent of sex-trafficked minors experience post-traumatic stress disorder,” Neal said. “These kids need long-term care to fully recover from their experiences.”

•••

Cotie didn’t have the help the School of Medicine provides, but for a while, she did benefit from UofL’s STAAR sessions at the Kristy Love Foundation.

After one particularly intense group session in May, Cotie emerged from the group in tears. She initially agreed to be photographed for this story, but was in no shape to participate. She rescheduled for two days later. By that time, however, Cotie had disappeared.

“It happens sometimes,” Renfro said. “We pride ourselves on being a home, and people come to the home and people leave the home. But we always take them back. They always can come back home.”

The care providers and researchers know the help they offer can be what finally makes a difference in the lives of survivors like Cotie. Unfortunately, victims often leave treatment programs or stop asking for assistance. But Middleton and her UofL colleagues who have taken up the issue of human trafficking are committed to making a positive impact.

“We’re all really passionate about this issue and trying to combat it.”